Sustainable Development Goal (SDG) 3; Ensure healthy lives and promote well-being for all at all ages is one which underpins the efficiency of all the other SDGs. If we do not have access to health then the ability to work, learn and live are automatically compromised. Accordingly, achieving SDG 3.8 and 3.9 (3.d) which focus on accessing universal health coverage (UHC) for all, strengthening the capacity of all countries for detection as well as management of global health risks by 2030 is paramount. This blog article will focus on SDG 3.8 – accessing UHC, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all. It is no doubt that the key to achieving this goal is multifactorial and will involve seamless partnership between various sectors. While there are multitude of strategies as well as competing factors requiring prioritization, I believe it is worth drawing lessons from success stories. In this case, focusing on Rwanda’s healthcare system and transformative initiatives such as “Last Mile Health” in Liberia.
Around the world, over 1 billion people go their entire lives without ever seeing a health worker – due to limited access to healthcare facilities. The devastating thought is that the diseases these people die from are preventable e.g. pneumonia, diarrhea, malaria and malnutrition. These same thoughts were echoed by Dr. Raj Punjabi, CEO of Last Mile Health Organization. This is an organization created to reach communities in hard-to-reach areas called “Last mile”. A last mile community is one which is more than 5 KMs from the nearest clinic. Most communities served by Last mile health are over 21KM from a facility. According to a recent report published by leaders from the United Nations (UN), World Bank, Liberian and Ethiopian Heads of State and others, there is a universal agreement that Community Health Workers (CHWs) particularly paid and professionalized CHWs integrated into health systems are a game changing investment that could provide economic return of 10:1. The Ministries of health need to ensure what ever discussions occur on an international level transcend to national and community level.
The organization called “Last Mile health” based in Liberia provides us with a snapshot of the fundamental benefits of community-based delivery of services via CHWs. After Liberia emerged from the civil war in 2003, the countries’ health infrastructure was almost non-existent, with only 50 doctors left in the country to attend to a population of 4 million. The aim and vision of this organization was to increase access to health of people in remote villages. This was achieved by creating a new workforce of CHWs by recruiting, training, equipping, managing and employing community members to provide health care in their own villages and subsequently link them to local health systems. The role and importance of CHWs, were greatly felt during the biggest Ebola outbreak in West Africa, and in Liberia specifically. The CHWs receive a complete rigorous training program of 12 months designed for the needs of that community. The different sectors include community health and surveillance, child health, maternal & neo-natal health and adult health. President Ellen Johnson Sirleaf has demonstrated attaining UHC in Liberia is priority. On the 24th of July 2016, she launched the first national CHW initiative called the National Community Health Assistant (CHA) program. The program will employ 4000 CHWs to across Liberia to serve the 1.2 million Liberians (29% of the population) in the “last mile”. Liberia will join the likes of Brazil, Bangladesh, Ethiopia, Thailand, Pakistan and Zambia who have previously gained success with similar initiatives. This integrated program will create thousands of rural jobs, hasten and greatly contribute towards the achievement of the SDG3 (universal coverage). The healthcare system of Liberia could be strengthened and thereby ensure the rise of another outbreak doesn’t transcend into a global epidemic.
Rwanda is a small country in East Africa with a population of over 11 million residents and its success in attaining the Millennium Development Goals (MDG) currently reflected in SDG3 are very prominent. Since the 1994 genocide, as Tony Blair, former British Prime Minister duely noted, “Rwanda, desperately poor, without skilled labor and resources and the people demoralized and divided, found itself in an unprecedented situation”. Part of the post-genocide development strategy was to attain the MDG. To the surprise of several, Rwanda was one of the few African countries on target to meet the MDGs by September 2015. Deaths from HIV, TB and malaria dropped by 80%, maternal mortality dropped by 60%, life expectancy doubled. In addition, the average healthcare cost was $55 per person per year. Among the key factors contributing to sustained progress, Rwanda highlighted the key roles of CHWs in the progress towards the MDGs. I recently highlighted the importance of community-based delivery systems of medication, health services and social work in an article titled “Healthcare systems in Sub-Saharan Africa; Focusing on community based delivery (CBD) of health services and the development of local research institutes”. The reduction in child mortality rates, the ability to diagnose and treat malaria, diarrhea and pneumonia were attributed to the ability of the CHWs bringing health services closer to the population. CHWs were provided with specially programmed mobile phone messages (Rapid SMS) to ease contact to health facilities thus allowing referrals.
These examples point to the importance of having CHWs in our health systems and achieving SDG 3, moving forward financing and funding such initiatives will be critical. CHWs are usually left vulnerable due to “informal work status”, this frequently affects the salaries of CHWs. Financing of CHW programs need to trickle right down to CHWs in form of wages and compensation. This will alleviate the vulnerabilities of CHWs and ensure rightfully deserved benefit for the substantial amount of work carried out. The initial implementation of CHW programs in most countries are as a result of partnerships between various donor organizations such as; The United Nations Children’s Emergency Fund (UNICEF,) the private sector and governments. While government investment in health has increased from 1.7% to 2.6% of Gross Domestic Product (GDP) in 1995 and 2013 respectively, if the African Union (AU) countries increased government expenditure as agreed in the Abuja declaration in 2001, which asks governments to give 15% of GDP to health, there will be up to $29 billion available towards health expenditure.
The sustainability of CHWs have been challenged by adequate and continued training and CHWs financing. In Rwanda, the initial training has been subpar as most CHWs ended up having on-the-job training. This is a challenge that needs to be met fully to ensure effectiveness of CHWs. In Pakistan, the female health workers receive 3 months initial training and in India a 12- 18-month distance learning course. In Liberia – Last Mile health, the CHWs receive a 12-month rigorous initial training. These are programs that have proven successful and should be adapted in the implementation of CHWs. The Ministry of Health in Rwanda uses community performance-based financing (cPBF). This is a remuneration mechanism is based on outputs and the CHWs are not provided monthly salaries. In Tanzania, Community Health Agents (CHAs) are formally remunerated as well Health Extension Workers (HEW) as in Ethiopia. This is a system that should be revised as CHWs without monthly payments have high attrition rates.
The sustainable continuation of these practices will entail investment in training of CHWs, strengthening the programs, mobilizing the communities, ensuring full participation of the communities and guaranteeing compensation of CHWs. Various over-aching themes which have been addressed above affect this goal directly or indirectly; good governance and financing. While it may be daunting to think of the various parties required for the universal success of this goal, it is vital to focus on the success stories of countries like Rwanda and the government of Liberia’s new initiative in partnership with Last Mile Health.